Caring for the patient with cardiac disease Flashcards
Atheroslerosis aka Atherosclerotic Heart Disease (ASHD)
- coronary artery disease leads to infarction
Congestive Heart Failure (CHF)
(2)
- dilated ventricles with weak muscles
- thickened myocardium
Valvular disease
(3)
- stenotic and not capable of full closure for blood circulation
- lack of tonicity also leads to stenosis
- leads to CHF
Caring for the patient with cardiac disease
layman presentation
coronary artery -
heart valve -
congenital heart -
arrhythmia -
heart failure -
heart muscle -
arteries that supply oxygen and blood to the heart become narrow
one or more of the valves in the heart are not working well
children may with this disease
abnormal heart rhythm
heart does not have enough strength to pump
heart walls become thick or heart becomes enlarged
Caring for the patient with cardiac
disease
Symptoms
(10)
- General weakness
- Fatigue
- Light headedness
- Dizziness
- Fainting
- Shortness of breath with mild exertion
- Chest pain
- Palpitations
- Hypertension
- Edema of the legs and ankles
CVD Risk Factors
conditions (5)
HBP
high cholesterol
diabetes
rheumatic fever
>1 CVD
HBP (2)
- Stiffens vessels which reduces blood flow
- also a risk for stroke, kidney disease and dementia
high cholesterol
LDLs
diabetes
unstable glucose levels affect myocardium fnx; angiopathy
CVD Risk factors
behavioral (6)
unhealthy diet - Carbs, fats, caffeine, Na+
physical inactivity - poor circulation
obesity - Excess weight stresses heart function, HTN, CAD
too much alcohol - increases BP, arrythmias
tobacco use - increases HR, BP, CAD, etc
stress
family hx (3)
genetics
becoming older
ethnicity
Atherosclerotic plaques can lead to:
(2)
- ischemia
- thrombosis, (vascular blockage) if they
rupture
Atherosclerosis
* Can affect arteries of:
(5)
➢ Heart
➢ Aorta
➢ Brain
➢ Kidney
➢ Peripheral arteries
Atherosclerosis
may not
may be
progress
asymptomatic - Plaques themselves do not
usually produce symptoms
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Dental Procedure Categories
type 1
exams, radiographs, oral hygiene instructions, study model impressions
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Dental Procedure Categories
type 2
simple operative dentistry, ortho
skipped
Dental Procedure Categories
type 3
adv operative dentistry, SRP, endo
skipped
Dental Procedure Categories
type 4
simple extractions, curettage/gingivoplasty
skipped
Dental Procedure Categories
type 5
multiple extractions,
flap surgery or gingivectomy,
extraction of single bony impaction,
apicoectomy,
single implant placement
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Dental Procedure Categories
type 6
full arch/full mouth extractions or flap surgery,
extraction of multiple bony impactions,
orthognathic surgery,
multiple implant palcement
Low Level Intervention
(6)
- Health/medical evaluation
- Exams
- Prophy
- Radiographs
- Optical oral scans
- Alginate impressions
Moderate Intervention
(4)
- SRP (scaling and root planning)
- Simple restorative procedures; 1-2 teeth
- Simple extractions; 1-2 teeth
- Restorative impressions needing retractions
and longer setting times
High Risk Intervention
(6)
- Complex restorative procedures on >2 teeth
- Multiple extractions
- Surgical extractions
- Implant placement
- Full arch impressions
- Dental care under general anesthesia
time of procedure is proportional to
risk category
The less the symptoms
and the better the
control of risk factors
THEN
- the better a patient
manages the stress
AND - the less likely the
patient will have a life
threatening incident
during a dental
procedure
The greater the symptoms
and the poorer the
control of risk factors
THEN
- the worse a patient
manages the stress
AND
the more likely the patient
will have a life threatening
incident during a dental
procedure
Hypertension (HTN):
- ?
- Depending on location of flow, it damages endothelium which leads to
(2)
- Same issue of altered flow creating risk for (3)
Stiffens vessels which reduces blood flow
clotting disorders and more infarct risk
stroke, kidney disease and
dementia
Hypertension
Increases Risk for:
(7)
- Myocardial infarction
- Stroke
- Coronary artery disease
- Peripheral artery disease
- Heart failure
- Retinopathy
- End-stage renal disease
normal bp
<120 and <80
elevated bp
120-129 and <80
HTN stage 1
130-139 or 80-89
HTN stage 2
> 140 or >90
HTN stage 3
> 180 and/or >120
Blood Pressure
NO dental care at UMKSC SOD if BP
➢ – is classified as a Hypertensive Urgency by the AHA based on
2017 guidelines
➢ Urgent referral →
➢ If patient is symptomatic →
≥ 180/110 mmHg
180/120
see doctor ASAP
Emergency Room
ACE inhibitors (3)
angioedema
neutropennia/agranulocytosis
taste disturbances
anti-arrythmics, class 1
sodium channel blockers
(3)
dry mouth
gingival ovoerrowth
hypersensitivity reaction syndrome
ca channel blockers
gingival overgrowth, dry mouth, taste disturbances
diurects
(1)
dry mouth
Hypertension
Oral Manifestations
None due to hypertension itself
* Side-effects of pharmacotherapy:
(7)
➢ Dry mouth (anti-adrenergics and diuretics)
➢ Burning mouth (ACEi)
➢ Taste changes (antiadrenergics, ACEi)
➢ Angioedema (ACEi, ARB)
➢ Gingival hyperplasia (calcium-channel blockers, what are the other 2?)
➢ Lichenoid reactions (thiazides, methyldopa, propranolol, and labetalol)
➢ Lupus-like lesions (hydralazine)
Gingival Hyperplasia – a side-effect of pharmacotherapy:
(2)
➢ amlodipine (Norvasc) a CA channel blocker – anti-HTN; less common side
effect, BUT…
➢ nifedipine (Adalat) a CA channel blocker
marked edema
Gingival Hyperplasia – a side-effect of pharmacotherapy:
➢ — anti-epileptic – occurs in 50% of patients on this medication
➢ ethosuximide (Zarontin) – anti-epileptic
➢ lamotrigine (Lamictal) – anti-epileptic
➢ phenobarbitone (Luminal) – anti-epileptic
➢ primidone (Mysoline) - – anti-epileptic
➢ topiramate (Topamax)
➢ vigabatrin (Sabril)
Phenytoin
Gingival Hyperplasia – a side-effect of pharmacotherapy:
➢ Cyclosporins (an immune suppressor –
anti-graft rejection; less common
side effect, BUT.. marked edema
Gingival Hyperplasia – Treatment (5)
➢ Modify medication with a consultation to the prescribing physician
(cardiologist, neurologist, etc
➢ Laser excision with scaling and curretage
➢ Electrosurgery – excise overgrowth tissue with control of hemorrhage
➢ Gingivectomy - excise affected tissue and reduce with sutures.
➢ Periodontal flap surgery – scale teeth and curettage of inflamed tissues with
flap access tp affected tissues
Gingival Fibromatosis
● generalized or localized increases in the volume of
gingiva
Gingival Fibromatosis
manifests with the onset of
eruption of the
permanent or primary teeth, or with the eruption of
primary teeth
Gingival Fibromatosis
may occur as
(3)
- an isolated feature
- part of a syndrome
- medication related
Hypertension
Medical Management
* Lifestyle modifications
(3)
➢ Diet (increase fruit intake, decrease sodium, increased potassium)
➢ Physical exercise/weight loss
➢ Tobacco cessation and alcohol intake reduction
Angina Pectoris
* Chest pain resultant from ischemic changes
➢ Mid-chest pain described as
o “aching, heavy squeezing pressure or tightness”
Angina Pectoris
Pain may radiate
➢ Shoulder, arms, jaw
Angina Pectoris
Pain lasts
5-15 minutes
➢ If unstable angina, may be longer
Angina Pectoris
— used to resolve angina
Vasodilation
Stable
➢ Imbalanced —
➢ Stable symptoms, (3)
➢ Chest pain precipitated by —
➢ Resolves with —
➢ Responds to —
cardiac perfusion
reproducible, predictable, consistent
physical activity/exertion
cessation of activity
nitroglycerin
Unstable
➢ Disruption of —
➢ Possible (3)
➢ Symptoms —
➢ Chest pain at —
atherosclerotic plaque
partial thrombosis, embolism or vasospasm
increasing
rest or with less intense physical activity/exertion
Congestive Heart Failure (CHF)
(2)
- dilated ventricles with weak muscles
- thickened myocardium
CHF
Symptoms
(10)
General weakness
Fatigue
Shortness of breath with mild exertion
Light headedness
Dizziness
Fainting
Chest pain
Palpitations
Hypertension
Edema of the legs and ankles
Valvular Disease
(2)
- Compromised function of the heart valves
- Valves direct blood flow into different heart chambers
- Valves direct blood flow into different heart chambers
(2)
➢ Atrioventricular:
o Tricuspid and Mitral
➢ Semilunar
o Aortic and Pulmonary
Valvular Disease
* Valves open and close
~
100,000/QD
Valvular Stenosis
➢ Do not open properly
Valvular Insufficiency
(2)
➢ Do not close properly
➢ Associated with regurgitation
Valvular Heart Disease
Risk Factors (other)
(3)
- Calcifications
- Congenital defects (bicuspid aortic valve, mitral valve prolapse)
- Infections
Valvular Heart Disease
Signs
(4)
➢ Murmurs
➢ Syncope
➢ Heart failure
➢ Shortness of breath
Valvular Heart Disease
Symptoms
(3)
➢ Heart failure
➢ Exercise intolerance
➢ Shortness of breath (can also be a symptom)
Valvular Heart Disease
Medical Management
(2)
- Treatment is primarily surgical
- Valve replacement (more common)
Valve replacement (more common)
➢ Mechanical Implants
(2)
o Silicone
o Requires long-term anticoagulation
Valve replacement (more common)
➢ Bioprosthetic Implants
(3)
o Allograft , bovine graft, etc.; decellularized CT
with a less antigenic structural matrix
o short-term anticoagulation
o Long-term antiplatelet therapy)
Valvular Heart Disease
Predisposition for
infective endocarditis
Valvular Heart Disease
Dental Considerations
(4)
- Assess ability to tolerate care in context of underlying condition and
comorbidities - Assess Bleeding Risk
- Infections
- Drug Effects
VHD
* Infections
➢ Determine need for
antibiotic prophylaxis and antibiotic of choice
VHD
* Assess Bleeding Risk
(2)
➢ Obtain INR the day of the invasive procedures
➢ Have local hemostatic measures in place
VHD
Drug Effects
➢ Review medication list
(2)
o Drug adverse effects
o Drug-drug interactions
prophylatic abx are generally recommended only for
high risk category
High Risk-
(5)
Mechanical prosthetic heart valve
Natural prosthetic heart valve
Prior infective endocardititis
Valve repair with prosthetic material
Most congenital heart diseases
akers/ defibrillators
Moderate Risk-:
(4)
Valve repair without prosthetic material
Hypertrophic cardiomyopathy
Mitral valve prolapse with regurgitation
Acquired valvular dysfunction
Low Risk-
(4)
Innocent heart murmurs
Mitral valve prolapse without regurgitation
Coronary artery disease
People with pacem
Infective Endocarditis
Conditions that DO NOT require Antibiotic Prophylaxis
(5)es
- Heart murmur
- Mitral valve prolapse
- Mitral valve prolapse with regurgitation
- Rheumatic fever
- Stent or coronary artery bypass graft (cabg)
- Note: If a heart murmur is due to specific cardiac condition (e.g., previous
endocarditis, prosthetic heart valve, complex congenital cyanotic heart
disease), AHA continues to recommend
antibiotic prophylaxis for most
dental procedur
Infective Endocarditis
Procedures that DO NOT require Antibiotic Prophylaxis
(4)
- Radiographs
- Placement of appliances
- Routine local injections
- Tooth shedding or trauma
Infective Endocarditis
Procedures that DO NOT require Antibiotic Prophylaxis
* Radiographs
* Placement of appliances
* Routine local injections
* Tooth shedding or trauma
These procedures are unlikely to:
(3)
- Manipulate the gingival tissue
2.Manipulate the periapex of teeth
3.Perforate the oral mucosa
Antibiotic prophylaxis is recommended for
ONLY AT RISK PATIENTS who have
procedures that:
(3)
- Manipulate the gingival tissue
2.Manipulate the periapex of teeth
3.Perforate the oral mucosa
OBS.: If the dosage of antibiotic is
inadvertently not administered before the
procedure, the dosage may be administered up
to — after the procedure.
2 hours
Infective Endocarditis
Patients already taking antibiotics
If a patient is taking a beta-lactam (penicillin, amoxicillin, etc.) for an
active, existing infection resistant strains have likely been selected
* If urgent/emergency dental treatment is necessary
➢ Prescribe
azithromycin or clarithromycin (i.e., macrolides)
IE
* If dental treatment is elective
➢ Wait 10 days after completion of the antibiotic for their
active infection, then prescribe amoxicillin according to
AHA guidelines
Infective Endocarditis
